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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803895
Report Date: 05/19/2021
Date Signed: 05/26/2021 09:36:05 AM

Document Has Been Signed on 05/26/2021 09:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MAGNOLIA GOLD HOME CAREFACILITY NUMBER:
486803895
ADMINISTRATOR:MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:1515 MARIPOSA WAYTELEPHONE:
(510) 220-6484
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 3DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gwen Martinez and Madonna MartinezTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required inspection and met with Licensee, Gwen Martinez, and Administrator, Madonna Martinez. The annual inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed a screening station at the entrance of facility which had hand sanitizer, a thermometer, a box of surgical masks and gloves, and a visitor sign-in sheet. Licensee took LPA's temperature and LPA signed visitor sign-in sheet. LPA and Administrator discussed documenting temperatures and screening questionnaires. LPA conducted a walk-through of the facility and observed COVID-19 postings. Facility screens residents twice per day and staff/visitors are screened for COVID-19 symptoms upon arrival. Staff clean and disinfect the facility daily and as needed (high touched surfaces are disinfected regularly/after use). Licensee confirmed 25% of staff are surveillance testing weekly. LPA observed 3 residents in care, all three were in their rooms upon arrival and later were observed enjoying lunch. Facility staff have completed PPE training and N-95 Fit testing is in process.

Facility has submitted a COVID-19 Mitigation Plan and it was approved. LPA observed a supply of PPE including gloves, face shields, masks and gowns. All staff wore face masks during this visit.

LPA and Administrator discussed questions regarding regulations and facility files (for staff/resident, emergency disaster drills, and medication).

LPA requested updated facility forms to be submitted to Community Care Licensing (CCL) for the facility file. Exit interview conducted with Administrator, whose signature on this document confirms receipt.



No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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